SFD (0302-040)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
777695? L1 4A:3O,�Ct.q
-D �� T Signature of Contractor,; �¢ ----
OWNER-BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the,project (Sec. 7044, Business & Professionals
Code). '
( ) I am exempt under Section B&P.C. for this reason
Date Signature of Owner
r
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
(,) I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided ;for;,15y Section 3700 of the Labor ,Code, for the
performance of the work for which this permit is issued.
�f, I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of the work for which this
permlt.is issued. My workers'.' compensation insurance carrier & policy no. are:.
Carrier . L,111F Tv M.0 1'UAL F: Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that.in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
pate: �j Applicant ,�
Warning: Failure to secure Workers' Co pensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for .a permit subject to the conditions and restrictions set forth on his
application. '
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employee
2. Any permit issued as a result -of this application becomes null and void
work is not commenced within 180 days from date of issuance of suc D j
permit, or cessation of work for 180 days will subject permit to cancellatio i
I certify that I have read this application and state that the above information. i
correct. I agree to comply with all City, and State laws relating to the buildin
construction, and, hereby authorize representatives of this City to enter upo
the above-mentioned property for inspection purposes..
I Y,Signature (Owner/Agent) AW f&ZZ- • Date14,
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BUILDING PERMIT PERMIT#
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DATE VALUATION �y, LOT TRACT
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ADDRESS
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OWNER
CONTRACTOR / DESIGNER / EN (NEER "
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CAS P2260
T'�P;F.,M DRIP= CA 912•60
(3-60)(04-9699 C330, 1832
USE OF PERMIT
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MECIMNICM, 11M1 di1-1300 l ��+0a F;! x.40
XLECTRI hL M&O 1.01.000-420-000 X194,'!3
PLUMBEHO FRE 101-000-4,19-000
STitOW0 f►iDTION FRE - USID 101-000-241-000
CiPI&INNO T?I11r 101.000.4 -000 ? $00
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FEB, 2 Q •.2003
CITY OF LA QUINTA
!PT°' v ' -^ `-DAT.EeJ
BY
DATE FINALED
INSPECTOR
fLh �
.P>4L`Yl
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
'
Slab Grade
3
Return Air
Steel
Combustion Air
Roof Deck-
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
_
Compressor
Insulation
_
Vents
Fireplace P.L.
_ _
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
03
Final
(�—
Final
`' `
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
_ Zip
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice
_
`
(Gas)
ELECTRICAL APPROVAL'S
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
' V- V " \�y